Provider Demographics
NPI:1356647424
Name:MOORE, TAMMY LYNN
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 OLD MONROE RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5305
Mailing Address - Country:US
Mailing Address - Phone:704-821-6551
Mailing Address - Fax:704-821-5247
Practice Address - Street 1:4300 OLD MONROE RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5305
Practice Address - Country:US
Practice Address - Phone:704-821-6551
Practice Address - Fax:704-821-5247
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist